Medical Home Answers to Some Questions

The medical home is a conceptual and functional practice re-design in primary care that emphasizes care coordination, continuity, evidence-based practice, enhanced access, and payment reform.

The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving a child's medical record and for coordinating care. Its revised definition now includes these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.

In early 2007, four primary care specialty societies (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association) developed seven principles that characterize the medical home:

Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:

Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient's family.

Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.

It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.

It should support adoption and use of health information technology for quality improvement;

It should support provision of enhanced communication access such as secure e-mail and telephone consultation;

It should recognize the value of physician work associated with remote monitoring of clinical data using technology.

It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).

It should recognize case mix differences in the patient population being treated within the practice.

It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.

It should allow for additional payments for achieving measurable and continuous quality improvements.

These points, now often referred to as "the seven joint principles," appear to represent the current working definition of the medical home.

There are many Medical Home demonstration projects underway, and they allow participation of medical practices based on different criteria. Some include participation of public and private payers and allow practices to include all patients. More often the projects have focused on patients who have specific or multiple chronic conditions, and are limited to those patients with a few participating payers. There is at least one Medicaid demonstration project that focuses on women with high risk pregnancies. Although definitions vary and continue to evolve, at the heart of a patient centered medical home is a medical practice committed to organizing and coordinating care based on patient's needs and priorities, communicating directly with patients and their families, and integrating care across settings and practitioners. The Medical Home is always centered on the patient; hence the name Patient Centered Medical Home (PCMH).

Why is the Medical Home important?

Interest in the medical home continues to increase. The Patient Centered Primary Care Collaborative (PCPCC) has been vigorous in their support of private and government supported demonstration projects. Members of that Collaborative include health plans and large employers, as well as groups representing physicians and other providers. Whereas the AAP initially developed the model as a way to improve patient care, the most obvious reason that the health plans and employers are supportive is that they are looking for ways to change the way medical care is provided in order to slow down the growth in health spending.

The expectation is that the providers who coordinate care for the patients will see financial rewards for their efforts, yet the overall cost of care will decline and care will be improved. The demonstration projects that are underway include various models for rewarding the healthcare providers who are coordinating care. The results for both cost containment and for improved outcomes, to date, have been mixed. Nonetheless, there is rapidly growing support for expanding Medical Home projects.

Recognizing the importance of the Medical Home concept, ACOG's Executive Board issued a policy statement following their February 2009 meeting that defines the principles and supports development of demonstration projects for patient centered medical homes for women (see below).

As women's health care providers and advocates, we believe in the importance of Patient Centered Medical Homes for women. The medical home concept holds great promise for reaching the shared goal of helping American women grow-up healthy, stay healthy, and age well. We are committed to ensuring that policy makers recognize the unique health care needs of women and the special importance of a women's medical home in meeting those needs.

We are committed to ensuring the following principles of a women's medical home:

A seamless continuum of care for women across their life spans. A medical home for women links wellness and preconception care with prenatal care and family planning; these are linked with medical care, screening and follow-up care for health needs later in life.

Patient choice, affordability and access. Every woman should have open access to a medical home with a choice of qualified providers and in a variety of settings. Comprehensive integrated care is especially important for low-income women who are uninsured and underinsured.

Accountable to women. Care is patient and family centered, culturally appropriate, structured to ensure women receive complete and accurate health information to make their own health care decisions, and structured to assure confidentiality so that teens and women seek needed care in a timely way.

Team care led by a physician. The patient's personal physician leads a team that collectively takes responsibility for ongoing care. For many women, their obstetrician-gynecologist serves as their personal physician and is the only provider that women see regularly during their reproductive years.

Care is evidence-based with continuous quality improvement. A medical home for women is structured to encourage health care providers to pursue practices that achieve evidence-based outcomes so that women will enter their reproductive years healthy, maintain their reproductive health, and age well.

Investment in interdisciplinary health education and training of providers. To understand and fulfill the functions of a medical home, innovative models of interdisciplinary education are essential.

Reimbursement that reflects the added value of a women's medical home. Reimbursement must reflect the costs of HIT, care coordination, additional staffing and other requirements needed to fully develop a women's medical home, and allow practices to share in any potential cost savings from the medical home practice model.

ACOG urges Congress to establish a women's health medical home demonstration program that would include community health centers and integrated private practices in 5 or more geographically diverse areas.

Where can I find additional resources about the PCMH?

This list of resources will help explain some of the expectations that stakeholders have for the Medical Home.

ACOG has developed a toolkit to help practices better understand expectations, and to help prepare a practice to become a PCMH. It is available on-line.

The American Academy of Pediatrics has developed a toolkit to help practices become Medical Homes, with checklists and links to additional information. You must sign in to use the "Building Your Medical Home" toolkit, but AAP membership is not required. Though focused on pediatric care, most of the information can be applied to any practice: http://www.pediatricmedhome.org/

The Patient Centered Primary Care Collaborative (PCPCC) offers numerous resources, including booklets that explain the PCMH, lists of demonstration projects, a resource guide for using health IT to support the PCMH, and a purchasing guide for payers: http://pcpcc.net/

In early 2008, the National Committee for Quality Assurance (NCQA), in collaboration with four medical specialty societies (AAFP, ACP, AAP, and the AOA) and the PCPCC, further refined the concept by defining specific practice standards and reporting measures. They offer an accreditation program which can result in one of three levels of recognition. This accreditation is limited to the medical specialties that collaborated with the NCQA to develop the criteria: pediatrics, family practice, general internal medicine, including osteopathic physcians in those specialties. Practices seeking accreditation complete a Web-based data collection tool and provide documentation that validates responses. Though the NCQA charges practices to become accredited, they offer many resources free of charge through their web site: http://www.ncqa.org/tabid/631/default.aspx

Conclusion

It is too early to determine whether many ACOG members will want to transform their practices into PCMH's. Depending on the current operational design of a medical practice, transforming into a Medical Home may require extensive investment of resources and changes in processes. Financial rewards are currently uncertain in most instances. Nonetheless, whether or not a practice chooses to become a PCMH, it is increasingly important for obstetrician/gynecologists and their medical office staff to understand the expectations of patients, payers, and other providers as this concept evolves and its acceptance grows.